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Civil vs. Criminal Healthcare Fraud Cases

Mishandling an accusation of healthcare fraud can cost you and your facility millions of dollars in fines and potentially result in a prison sentence. Knowing how prosecutors coordinate civil and criminal investigations can save your practice, reduce individual and corporate penalties, and help you navigate your career seamlessly through a complex legal battle.  Lowther Walker [...]

Medicare Payment Suspensions: What Healthcare Providers Need to Know in Response

Pursuant to 42 C.F.R. §405.371(a)-(c), Medicare payments to participating providers may be suspended, offset, or recouped by CMS or one of its authorized contractors This post explains the legal framework governing Medicare payment suspensions, the circumstances under which they are imposed, and the steps providers should take if they receive a suspension notice. Background: A [...]

How Does The Government Prove Intent In Healthcare Fraud?

Healthcare fraud is a specific intent crime, meaning the government cannot secure a conviction simply by proving that false claims were submitted. Prosecutors must demonstrate that the defendant knowingly and willfully acted to defraud — a standard that requires getting inside the mind of the accused. Here is how they do it. Intent Under 18 [...]

Healthcare Fraud Defenses Guide

Legal defenses for healthcare fraud charges challenge allegations of fraudulent billing for financial gain. Healthcare fraud prosecutions under statutes such as the False Claims Act, Anti-Kickback Statute, and Stark Law carry severe penalties. Providers can face prison, exclusion from Medicare and Medicaid, and the permanent loss of professional licensure. Mounting a strong defense is imperative. [...]

The Complete Guide to Healthcare Fraud Defense

For those facing healthcare fraud allegations, this complete guide to healthcare fraud defense explains the laws, the evidence collection process and the available defense options. [...]

MAC Audits vs. UPIC Audits: What Medical Professionals Need to Know

Medicare’s program integrity framework relies on multiple layers of auditing activity. For most providers, the two audit types most likely to affect day-to-day operations are those conducted by Medicare Administrative Contractors (MACs) and Unified Program Integrity Contractors (UPICs). Though both are federal audit mechanisms operating under the authority of the Centers for Medicare & Medicaid [...]